3. Discussion
According to our experience and previous reports, the laparoscopic
approach to cholecystectomy may be useful 6.
Pneumoperitoneum may increase the preload on the heart and cause vital
changes in LVAD patients 8. However, in this case, no
intraoperative change due to pneumoperitoneum was observed. In the
present study, we performed pneumoperitoneum at 10 mmHg. However,
previous reports suggest that a pneumoperitoneum at 10–15 mmHg is also
acceptable (Table 1) 6 9-23.
There are currently nine case reports and seven case series in the
literature, including 32 cases that described LC (Table 1). Of the 42
total cases (including the presented case), only one case (2.4%)
converted to open surgery. Nearly half of the patients (40.5%)
underwent scheduled elective surgery. This trend seems to be
particularly strong since 2015. We speculate that this change is partly
related to increased awareness of the acute cholecystitis guidelines24. i.e., the use of alternative methods such as
gallbladder drainage rather than emergency surgery in the case of organ
failure. However, the rate of PTGBD was not stated in many of the
previous reports; therefore, the overall rate is unknown. The safety and
efficacy of PTGBD have been confirmed by many case-control studies in
patients with cholecystitis. PTGBD is recommended as a standard drainage
method for patients with acute cholecystitis at high surgical risk24. In this case, the following factors contributed to
our success: 1) the acute cholecystitis was treated with PTGBD to reduce
inflammation before the scheduled surgery, 2) time was given before the
scheduled surgery to consider warfarin antagonism, and 3) the surgery
was performed in a calm circulatory state. In our case, the operation
was completed safely, with lower blood loss compared to the blood loss
in previous reports. Although our institution is not a heart transplant
hospital, LVAD transplantation is performed in the Department of
Cardiovascular Surgery at Tottori University Hospital. Patients with
LVADs are admitted to our hospital. As the number of patients with LVADs
is increasing worldwide, more cases of acute abdominal problems in
patients after LVAD transplantation will be encountered. The use of
PTGBD to reduce the cholecystitis before performing the LC is
beneficial.
In conclusion, we described the case of a patient with end-stage heart
failure and an implanted LVAD who was diagnosed with acute
cholecystitis. The patient was successfully and safely treated with
PTGBD followed by elective LC. In patients with LVADs who develop acute
cholecystitis, the use of early PTGBD to eliminate inflammation in the
biliary tract is useful. Awaiting surgery prevents fatal complications,
such as perioperative bleeding and biliary tract injury.